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01-1','.::,, ' 'v\ County /Pi <br /> / Safety and Buildings Division Dane --i t <br /> (tt n$ ' 201 W.Washington Ave.,P.Q.Box 7162 Sanitary Permit Number(lo be filed in by Cu.) <br /> e }e:P:- 1 Madison,WI 53707-7162 <br /> v11" ; j.'- 2©/ -c /ST- <br /> Sanitary Permit Application State Trmuoctims Number <br /> to accordance with SPS38321(2),Wis.Adm.Code,submission of this form to the appropriate governmental unit <br /> is required prior to obloining a sanitary pennii,Note Application foams for stole-owned POINTS ore submitted to Project Address(if different Mon mailing address) <br /> the Department of Solely and Professional Scn•tes. Personal information you provide may be used for secondary <br /> purposes in accordance with the Privacy Low,s 15.04(1 Man.Slats. Manhattan Drive <br /> I.Application information-Please Print AU Information <br /> Property Owner's Nome Parcel g <br /> Norbert Repka 0608-284-8440-2 <br /> Property Owner's Moiling Address Property Locution <br /> 3701 Basalt Lane Govt.Lot <br /> City,Stoic a Plicate NE % SE 4,Section 28 <br /> Madison,WI I3,719 213-0401 T 6 N; R 8 (C1rc Eon W <br /> II.Type of Building(check all that applyy �\ r Lot 0 <br /> RI 1 or 2 family Dwelling-Number of Bedrooula 5 ) 2 Subdivision Name <br /> \ Bieck g <br /> ❑Public/Commercial-Describe Use `-.A.— ❑City of • <br /> ❑State Owned-Describe Use CSM Number ❑Village of <br /> 5947 Cal Town of Verona - <br /> III.Typo of Permit: (Check only one hos on line A.Complete line B If applicable) <br /> A' kl:New System ysl I]Reptoccuieno System ❑Trewment/NokFiogTonk Replacement Only 0 Other Modification a Existing System(explain) <br /> B. ❑Permit Reneanl ❑PemsP Revision ❑Change of Plumber ❑Permit Transfer to New <br /> List Previous Pennit Number and Date Issued <br /> Before Expiration - Owner <br /> IV.Type of POINTS System/Component/Device:(Check all that apply) <br /> ❑Non-Pressurized In-Ground ❑Pressurized lmGroutd ❑At-Grade V Mooed>24 in.or suitable soil, ❑Mound<24 in.or suitable soil <br /> ❑Holding Teak ❑Other Dispersal Component(explain) ❑Pretreatment Device(explain) <br /> V.Dispersal/Treatment Area Information: <br /> Design Flow(gpd) Design Soil Appliation:Ratdgndst) Dispersol Area ed Dispersal Area Proposed 1st) System Elevation <br /> 750 / 1.0 /0.Co 750 (s0 2 Sv 760/i7w1 103.1 104.2' <br /> sq.Tim kInfo Capacity be Total 0 o Manufacturer <br /> Goilons Gallons Units a E u.1 0 <br /> New Toots Existing Tonto u c E <br /> lE_ <br /> c`U W 3 N L O 4 <br /> Sgoem Brains Tads 1000/600 1600 1 Dalmarav x <br /> Dosing ctiou r 750 750 1 Dalmaray x <br /> VII.Responsibility Statement-1,die undersigned,assume responsibility'/' �for installation at the POINTS shown an the attached plans. <br /> Plumber's Name(Print) Plumber's Stgmto V �/ MP/MPRS Number Business Phone Number <br /> -1:-‘:�0-1h, ... ee ytto ,; 7.5 5 6oe-Sy5-7,46 <br /> Plumber's Address(Street,�ity,State,Zip Code) _ —°-w-.......,...„ <br /> 1336 F N.,-1-z; Ref • VET&O, 1u . S35q 3--•._.._.P,...— <br /> VIII Eounty/Deparbnent Use Only ///JJ <br /> Approved ❑Disapproved -Permit Fe,t Q'b Date ..,ed Issui tSi at /rj`%�� i�/ <br /> ❑Owner Gilmn Reason Par Denial $) •It!b /, /7 <br /> Ix.Conditions of Approval/Reasons for Disapprove! <br /> ,aieer /Brie, /ire —'O 0145'4 '' off" ,pc,- -- /.e/ /T- .rr/ !o�✓dilN <br /> ll'r/'Pi1� <br /> -w- <br /> ile) l' 1.0)%el °'. 4`.refl.9#t1ry ,rJ/4"erl0 GF ...-.c 1,49//!4 -et'/S�1W, - <br /> OAx y p d' Sryi4i70, /14 r ,g,4 /.w•,era-67.) TV /r7' scum 1.1 .tr -1 T,'A,e -.45.-,0,./-6i <br /> Altoch to complete plans for the:Totem mu]sahmit to the Courtly only on paper not less then 8 n!s I t Inches In slue <br /> ., ED <br /> SBD-6398(R-I I/I I) SCANNED s;:i v i . Q17 <br /> Public H^-Z1'h MDC <br /> Environmental Health <br />